MiBo Fitness System™ Pre-Qualification Assessment Form ™   The purpose of this form is to evaluate your needs and provide you with a summary of how I can best help you. Please fill in all fields in order to provide you with the best possible assessment Check Off Any Areas that Interest You: MiBo One-On One Training MiBo DVD Series MiBo PodCast Series MiBo Team Training (Sports) MiBo Group Training MiBo ToGo - Fitness Needs for the Road Warrior Name* Email* City State Country Age* Best way to contact you * email phone Can you handle a totally new & different fitness system? Little Confidence Somewhat Confident Confident Very Confident Can you forget your preconceived notions about fitness? Little Confidence Somewhat Confident Confident Very Confident Can you physically work hard? Little Confidence Somewhat Confident Confident Very Confident Can you mentally work hard? Little Confidence Somewhat Confident Confident Very Confident Are you ready to be pushed to your physical and mental limits? Little Confidence Somewhat Confident Confident Very Confident Can you look at weights and exercise as only a means to achieving your fitness goals? Little Confidence Somewhat Confident Confident Very Confident Can you open your mind to different fitness styles? Little Confidence Somewhat Confident Confident Very Confident Can you handle using light weight, heavy weights or no weights to achieve your goals? Little Confidence Somewhat Confident Confident Very Confident Can you take instruction and follow direction? Little Confidence Somewhat Confident Confident Very Confident Can you visualize yourself achieving your fitness goals? Little Confidence Somewhat Confident Confident Very Confident Can I use food as fuel for my body instead of a source of entertainment and pleasure? Little Confidence Somewhat Confident Confident Very Confident Can you devote 3 to 4 hours per week to yourself to achieve your fitness goal? Little Confidence Somewhat Confident Confident Very Confident Do you have any known health issues? Please list them in the following area: Has your physician given you the ok to exercise? Yes No How would you rate your current level of mental and physical fitness? Poor Fair Good Excellent Have you ever worked with a Fitness Trainer before? Yes No Are you training for a specific event, occasion or sport? How do you currently work out? (Choose all that apply) I belong to a gym I work out at home I exercise at home I play recreational sports I play competitive sports I don't have a plan or routine right now How often do you work out currently? Twice a day Once a day Mon-Fri. - 5times/week 3 times/week once/week I don't workout Which of the following training times best suits your lifestyle and time availability? Any time, any day of the week Monday - Friday (daytime) Monday - Friday (evenings) I'd like to discuss this

Note that your results will be kept confidential and
will only be used to provide you with a suggested course of action. Before entering into any training program it is recommended that you consult your physician.

The MiBoFitness System™ involves regular and intense physical activity and it is important for your physician to know that you are embarking on a life-changing physical fitness program !

 

Sincerely,

Lyle Dennis